MEDICARE: ORTHODONTIC ASSOCIATES, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5275-015	WI

General Provider Information

NPI Number	:	1023237559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHODONTIC ASSOCIATES, S.C.

Provider Business Mailing Address
First Line	:	1510 DOCTORS CT
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-4102
Country	:	US
Telephone Number	:	920-261-3560
Fax Number	:	920-261-3561

Provider Business Practice Location Address
First Line	:	1510 DOCTORS CT
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-4102
Country	:	US
Telephone Number	:	920-261-3560
Fax Number	:	920-261-3561

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS GERARD BRADLEY
Credential	:
Telephone Number	:	920-261-3560

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	08/22/2020

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